QUESTION: "Twenty-four hours after delivery, the nurse documents that involution is progressing normally after palpating the client's fundus at which of the following locations?"
CHOICES
( O ) a.) Slightly below the level of the umbilicus.
( X ) b.) Midway between the umbilicus and the symphysis pubis.
( X ) c.) Barely above the upper margin of the symphysis pubis.
( X ) d.) Slightly above the level of the umbilicus.
RATIONALE: Approximately 24 hours after delivery, the height of the uterus is normally felt slightly below the umbilicus. Unless complications occur, this client can expect the fundus to descend at a rate of about 1 fingerbreadth per day. Immediately after delivery, the top of the fundus normally is midway between the umbilicus and the symphysis pubis. The fundus is barely palpable above the upper margin of the symphysis pubis 7 to 10 days after delivery. Palpation of the uterus above the umbilicus may indicate urinary retention or retained placental fragments. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
